The Fourth Floor at St. Paul’s
A personal reflection on addiction, care, and what I saw inside the safe consumption area at St. Paul’s Hospital.
I recently spent several days at St. Paul’s Hospital for a medical issue.
One evening I walked through the hospital’s fourth-floor safe consumption area.
What I saw there stayed with me.
Eventually I found myself outside on the sidewalk in front of St. Paul’s Hospital, an IV pole beside me, during one of the brief sleet-like snow flurries Vancouver has had this year.
I’m a smoker—well, a vaper actually—and I needed a moment outside.
People walking past glanced over and then quickly looked away. Some lowered their heads. Others shifted their path four or five feet around me.
The reflex was easy to read.
It’s too early in the day to start thinking about how I’ll say no to the guy ahead of me who’s probably going to ask me for money.
I saw it. It was real.
What they didn’t know was that I wasn’t part of the street scene they imagined. I was a patient waiting for answers inside the hospital.
But in another sense, I’ve spent much of my life standing not very far from that world.
I’ve worked in and around recovery for what sometimes feels like most of my life. I don’t celebrate that. Addiction took its own sweet time tying knots in the honest connections I had with people I loved. It ruined me financially more than once. It placed me in jail and in risky situations that I escaped only by the skin of my teeth. It removed me from my children’s lives and created fear in them and the rest of my family that burned for a long time. Some of that smoke is still there.
I’ve worked around the homeless, the mentally ill, and the severely addicted. I’ve watched people disappear—not literally in front of me—but they were there, and then suddenly they were not. Each carrying their own devastating, untold story of returning, even after long stretches of sobriety, to the only solution they knew.
Over the years I’ve watched the problem spread across our cities. Downtown first, then Mount Pleasant, then the North Shore and Burnaby. Port Coquitlam, Pitt Meadows, Mission, Kelowna, Alberta. What once felt local slowly revealed itself as something larger—a national problem, then a Western one, and now something we see across Europe and beyond: a social displacement of people, families, and communities into addiction.
This week a fairly serious medical concern landed me in the hospital.
It began as terrible pain—but with enough familiarity that I knew what it meant. Hospital. I even took a few minutes to put some things in order before leaving, because I suspected I would be there for a few days.
What it turned into was 12–16 hours in the emergency waiting room at St. Paul’s Hospital.
Where I sat in what felt like a rotating Fellini scene of frightened, painfully sick people. Some with loved ones beside them. Others simply alone, like myself.
And then, alongside all of this, were the mentally ill, the homeless, the drug addicted. People vomiting, screaming, ignoring security requests, demanding—through incoherent mumbles—better treatment, a different doctor, an explanation for why they had to wait.
But this isn’t really about me. Or even about the hospital, per se.
This is about the second night after I was diagnosed and told that I would need to stay, as I had guessed, for monitoring.
By that point I was finally able to walk around a little. I went in search of some small nook where I could hit the peachy-apple drug of choice.
I was happy to go all the way outside, of course. But after asking a maintenance staff member where people usually go, I learned about the fourth-floor safe-use area.
Perfect. My kind of place.
I was curious, even a little pleased, that I would be back among “my people,” so to speak.
What I didn’t expect was that walking through the first set of doors—clearly marked as the safe consumption area—I would feel as though I had been transported straight back onto Hastings Street.
A long semi-covered walkway stretched ahead, littered from one end to the other with trash.
Large pools of green mucus where people had spat it out. Cigarettes stuck to walls with spit. Used harm-reduction materials. Leftover clothing. Burns on the walls from lighters or matches. Spit stains everywhere. Graffiti—angry graffiti—calling out security staff and tagging people with street monikers.
Inside, past the tent where harm-reduction supplies and drug testing were available, there was a large courtyard.
Lovely wooden benches. Landscaped gardens and shrubs.
At first glance it looked like something Vancouver actually does very well: a green space for connecting with friends, or simply sitting quietly with ourselves. There was even a covered gazebo—something that might easily be imagined as a place for lunch or shelter from the rain.
But as I walked closer, it became clear that this was not an inviting area.
Seven men, heavily layered in street clothing, some in wheelchairs and others sitting on carts, were gathered together. Each one was smoking meth, exactly like the scenes we see driving down the 100 block of East Hastings.
How did it feel?
It didn’t feel good.
My first thought wasn’t pride in how well Vancouver is trying to ensure everyone receives medical care regardless of their status. I didn’t feel happy that the men had found a safe, dry place to use during the final grey days of a Vancouver winter.
I felt something else.
Something I hadn't expected.
I felt angry.
And now, back home, having received the medical care I needed—regardless of my own status—I find myself asking a different question.
Why do we still seem to miss the point that so many new people are entering the Downtown Eastside every year—especially young people?
We see them.
Fourteen.
Fifteen
Sixteen
Still with youthful energy. Still with youthful eyes, but already a few scabs on their faces.
Wearing clothes that, a year earlier, might have passed as a fashion statement. But now they signal something else entirely: someone who has lost interest in hygiene. Someone who has walked through a door that quietly removed the desire to be clean, to look clean, to appear not entirely helpless.
So I took a few photographs.
The next day I noticed the sign that said cameras were not allowed.
But I was never really interested in photographing the people themselves. What struck me was the filth. The disregard for the space.
I kept thinking: with all the money being spent on harm reduction, how is it that we allow this level of neglect in a public place?
How are we unable to say something as simple as:
If you want to use this resource, you are not allowed to spit on the walkway.
You are not allowed to write graffiti on the walls.
You are not allowed to burn candles wherever you feel like it.
And perhaps more importantly—why is no one cleaning it up?
Why, with all those dollars being spent, is someone not hired—even full time—to maintain a basic level of care and community standards? Out of respect for visitors, but also simply to model the most basic expectations of shared space.
I simply don’t buy it.
Critics will say these people should not be expected to follow those rules. That their mental illness or their addiction prevents them from making those kinds of decisions.
Most of us who have visited St. Paul’s have paused at the view of that ancient building standing against the skyline of the Wall Centre towers—the shiny glass and steel rising beside it.
And beside them stands the fading red-brick face of the hospital itself. The eerie old-world gothic towers rising from rooms where one can barely imagine what takes place inside them.
Ancient HVAC pipes and smoke stacks climb toward the sky. The fog of hospital life drifts upward from ground to air.
I’m glad I captured that image.
We don’t know what will become of this old place. But we can already see the nearly finished new hospital rising over on Main Street. It’s massive. Magnificent. Modern.
Eventually it will be surrounded by trees, gardens, and green spaces where people will sit with sick friends or loved ones.
I know that’s the intention.
But when I think about the fourth floor of St. Paul’s today, I imagine something else too.
I imagine devastated lives. A lack of hope. The near impossibility of reaching the mentally ill and acutely addicted.
I walked through that space myself. I saw it.
And I imagine their trails, their sleeping places, their homelessness taking root again in a new place—one that was built with the intention to “stop just one person from dying.”
